Friday, March 26, 2010

Psychiatry Public Trust Influence

Thomas Insel, MD, the director of the National Institute of Mental Health (NIMH) wrote an editorial in the most recent Journal of the American Medical Association discussing the relationship between psychiatry and pharmaceutical companies that have contributed to the increasing erosion of public trust in psychiatry. Now psychiatry has never had a positive image. I have often noted that in TV or film portrayals the psychiatrist is either a bumbling fool, a narcissistic jackass, or downright evil. There are some exceptions to this but they are few. Why might this be?

I think there are several reasons. First psychiatrists deal with mental illness that is still widely stigmatized, is poorly understood and often feared by those who don't understand. Secondly psychiatrists are the physicians who are associated with the whole ethical conundrum of involuntary treatment. Due to the nature of the illnesses involuntary treatment is occasionally necessary but is subject to great risk of abuse or misuse of power. Psychiatrists are the physicians who participate in forced hospitalizations and occasionally forced medication treatment. We also are associated with ill conceived barbaric treatments in the past such as unmodified and safely provided Electroconvulsive Therapy (ECT) and lobotomies. Safety of patients require occasional seclusion and restraint which are dangerous procedures fraught with ethical and practical difficulty, and have been overused. In addition I have often found that in social settings people often think that I am analysing them or can read their minds. But as Dr. Insel points out there is an additional problem that has eroded public trust in our profession and that is the relationship between psychiatry and pharmaceutical companies.

Psychopharmaceuticals are big money. Antidepressants and antipsychotics represent two of the top five drug classes sold in the United States today with sales of over $25 billion dollars per year. Although more prescriptions for these drugs are written by non psychiatrists than psychiatrists we are naturally associated with their use and have a large responsibility to see that these medications are used appropriately. There have been a few recent scandals in which it became apparent that data were falsified by well known and well respected academic researchers who were found to have close financial ties with the industry. A recent study indicated that 60% of all medical school department chairs have received personal income from the industry and 80% of all faculty reported such a relationship. A similar study showed much the same rates in non psychiatric medical disciplines but that does not excuse psychiatry. "Everyone is doing it" is not an acceptable rationalization.

Of 20 work group members who authored the American Psychiatric Association guidelines for the treatment of schizophrenia, bipolar disorder, and major depressive disorder 90% had pharmaceutical industry ties but none of this was disclosed.

What is especially sad to me is that the majority of psychiatrists that I know and have dealt with are good ethical people. Most are struggling with few societal resources to decrease the suffering of individuals with these devastating diseases and are doing the best they can with our limited state of knowledge. But that is not the public perception and the close ties with pharmaceutical companies has only made the situation worse.

Thought for the day

It is time to clean house.

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